This Policy Brief calls attention to the challenges faced by youth and young adults with mental health needs during their transition to adulthood and provides information to help policymakers at the state and local level develop and improve service delivery systems for this population.

While the transition from adolescence to adulthood is challenging for all young people, it can be especially difficult for youth with mental health needs who often face unemployment, underemployment, and discrimination when they enter the workforce. Adding to these challenges, youth with mental health needs often find it difficult to find or maintain services they need to successfully transition to adulthood including mental health treatment, employment and vocational rehabilitation, and housing. Providing appropriate services and supports to young people with mental health needs throughout the critical transition years increases their chances of becoming self-sufficient adults and reduces long-term dependency on public systems and other negative consequences such as social isolation and suicide.

According to the U.S. Government Accountability Office (GAO) (2008), over 30 percent of non-institutionalized young adults ages 18 to 26 had some degree of mental illness in 2006. Approximately 2.4 million young people, or 6.5 percent of the total non-institutionalized 18- to 26-year-olds, had a serious mental illness and 9.3 million, 25.3 percent of the total, had a moderate or mild mental illness in 2006. The number of young people with mental health needs is expected to be much higher if those who are homeless, institutionalized, incarcerated or undiagnosed were also accounted for in researchers’ estimates. The GAO found young people with serious mental illness have significantly lower rates of high school completion and postsecondary education compared to other individuals their age without serious mental illness or mild to moderate diagnoses. This finding emphasizes the need for programs targeting youth with serious mental health needs to include services and support that help them pursue and complete high school and postsecondary education credentials, both critical steps to obtaining competitive employment and financial independence.

No coordinated system currently exists to guide young people with and without mental health needs through the challenging task of entering adulthood. Due to the lack of coordination between public systems, young people with mental health needs find it difficult to locate and qualify for services tailored to their specific needs. While various discreet services are offered by different systems and agencies, they are typically not connected or coordinated, therefore they are ineffective. Youth with educational and career challenges, such as those with mental health needs, too often fall off one of the cliffs between youth and adult systems or get shunted down an arbitrary or inappropriate service tunnel based on considerations dictated by the system rather than the youth’s wants and needs.

Those youth who have succeeded in obtaining some services that suit their needs often experience service interruptions and discontinuity when they surpass the age of eligibility. Service continuity results from the common practice among public agencies of dividing service systems into those for children and those for adults. As a result, a young person being served by the child system, such as child mental health, may eventually “age out” when they surpass the upper limit of the system’s age defined eligibility criteria which may range from age 18 to 21. The child agency typically discontinues services to a young person who has aged out and refers him/her to the adult system. While services offered by the child agency may no longer match the young person’s needs related to transitioning to adulthood, the adult system may also be poorly suited to the needs of individuals entering young adulthood. In the mental health system, states’ eligibility criteria for public services for adults is typically narrower than the eligibility criteria for children. Such differences in eligibility criteria between child and adult systems cause many young people to lose access to treatment and support at a critical phase of their development.

In some cases, public services simply do not suit the specific needs of young people with mental health needs. For example, some programs serving young people with mental health needs find the stand-alone Workforce Investment Act (WIA) services offered by their local workforce development agencies are not appropriate for their youth clients. Reasons cited include WIA services are largely self-directed and lack intensity, accommodations are not provided unless young people self-disclose their disability, and stringent performance measures discourage workforce service providers from serving individuals who need more intensive and longer term support.

A 2005 survey of members of the National Association of State Mental Health Program Directors indicated few states have any programs focused on young adults and existing programs only serve a part of the state. The survey sent a clear message that “providing continuous and appropriate services for this age group cannot be achieved by any single agency” and highlighted the need for leadership at the federal, state, and local levels to ensure continuity of services and developmentally appropriate supports. Mental Health officials surveyed had the following recommendations:

set the transition period for youth with mental health needs at ages 16 to 30;

adjust definitions of mental health needs so that they do not screen youth out of needed services;

develop partnerships to expand service delivery; and

collect data and supporting research that will expand the limited research studies on youth with mental health needs.

The existing discreet services and programs available through child and adult mental health systems, Career and Technical Education programs, transition planning under the Individuals with Disabilities Education Act, Vocational Rehabilitation, and the Workforce Investment Act have the potential to operate together as a comprehensive system for transition to adulthood for all youth including youth with mental health needs if policymakers make concerted efforts to develop and support collaboration and coordination across various agencies.

A rich body of research about transition-age youth with mental health needs published in four separate reports in the last two years, including two produced by the National Collaborative on Workforce & Disability for Youth (NCWD-Youth) provides guidance to policymakers and other stakeholders on how to develop and improve service delivery systems for transition-age youth and young adults with mental health needs. The following are suggested action steps for state and local policymakers culled from all four reports:

Without a clear recognition of the many and varied needs of transition-age youth with mental health disorders, public systems have little impetus to change the way they currently do things. States and local communities that are developing and transforming services for transition-age youth will want to consider the research on what young people need to succeed in the transition process. The U.S. Department of Labor’s Office of Disability Employment Policy (ODEP), in collaboration with its technical assistance center NCWD/Youth created the Guideposts for Success, a comprehensive framework that identifies what all youth, including youth with disabilities, need to succeed during the critical transition years. The “Guideposts for Success for Youth with Mental Health Needs,” which incorporate all of the elements of the original Guideposts as well as additional specific needs relating to youth with mental health need, is a valuable resource for policymakers and youth service professionals who seek to provide young people with an intentional, integrated, well-coordinated, and comprehensive set of services and supports.

Based on an extensive literature review of research, demonstration projects, and effective practices covering a wide range of programs and services - including lessons from youth development, quality education, workforce development, and the child welfare system, the Guideposts for Success point out that all youth, particularly at-risk youth such as youth with mental health needs and other youth with disabilities, achieve better outcomes when they have access to

high quality standards-based education, whether they are in or out of school;

information about career options and exposure to the world of work, including structured internships;

opportunities to develop social, civic, and leadership skills;

strong connections to caring adults;

access to safe places to interact with their peers; and

support services and specific accommodations to allow them to become independent adults.

The Guideposts are a framework for assuring that all the needs of youth are being addressed, namely those related to: 1) school-based preparatory experiences; 2) work-based learning and career preparation; 3) youth development and leadership issues; 4) connections to adult and community-based programs; and 5) engagement of family and caring adults.

The Guideposts for Success for Youth with Mental Health Needs
And Related Reports

The complete document, “Guideposts for Success for Youth with Mental Health Needs,” is available online at /guideposts/mental-health and is also included in the full report:

Young Adults with Serious Mental Illness: Some States and Federal Agencies are Taking Steps to Address Their Transition Challenges, a 2008 report by the United States Government Accountability Office, (Report 08-678), available online at http://www.gao.gov/new.items/d08678.pdf.

To inform its 2008 report on challenges and strategies associated with the transition needs of young adults with serious mental illness, GAO visited four states – Connecticut, Maryland, Massachusetts, and Mississippi – that have established programs and policies specifically designed to address the needs of youth and young adults, ages 16 to 25. All four states have established multidimensional programs that offer a range of services from mental health care to employment and vocational rehabilitation to independent living skills. Some programs also provide housing assistance. While administered by state mental health agencies, the programs are locally operated by mental health authorities, non-profit agencies, and community based mental health providers. The delivery of services are integrated where possible so that young people can access multiple services in one location or through one program rather than seeking them out individually from multiple, discreet programs. The programs also aim to tailor services to the individual needs of each young person. States report that some young people receive an intensive array of services while others may only receive one type of service depending on his or her specific needs.

In Massachusetts, the Department of Mental Health administers the Transition-Age Youth Initiative which provides an array of age-appropriate services to individuals ages 16 through 25 that address their needs in the areas of mental health treatment, vocational rehabilitation, employment, housing, peer support, and family psychoeducation. The initiative was established in 2005 after the agency discovered a declining number of young adults transitioning out of the children’s mental health system were requesting services. State officials found the adult mental health program was not providing the types of transition services needed by youth and young adults. In response, it developed the initiative to specifically serve youth with mental health needs transitioning from the children’s mental health system to the adult system and those aging out of foster care or the juvenile justice systems.

The tailored and integrated multi-services strategy employed by the four states reviewed by GAO is consistent with successful strategies identified through case studies of promising transition-age youth programs conducted by the ODEP at the United States Department of Labor, through NCWD/Youth. According to the 2007 study by Woolsey & Katz-Leavey, promising programs that help young people with mental health needs overcome challenges in the transition to meaningful employment and independent living shared the following design features:

Program locations that are distinct and separate from adult service program locations;

Staffing choices that promote engagement of youth and young adults;

Individualized mental health interventions that are youth-friendly and innovative, assisting youth/young adults in managing their conditions, engaging in social relationships, identifying life goals, and understanding their choices for achieving those goals;

Assessment and service planning processes that facilitate the identification of individual strengths, talents, and skills that can lead to education and career goals;

Exposure to the world of work and career options, including individualized support by program staff to identify training, work-based experiences, and jobs that are most appropriate and rewarding for individual clients; and

Access to a range of transitional housing options in the community that fit the individual’s readiness to live independently.

Supporting Transition with Mental Health Recovery Models

The following mental health recovery service delivery models offer promising ways to overcome the challenges of service tunnels and transition cliffs and to provide an effective, integrated, self-directed system of care for youth and young adults with mental health needs:

Transition to Independence Process (TIP)

The TIP approach is an evidence-based program model that stresses the importance of providing access to appropriate services, engaging young adults in their own future planning process, and utilizing services that focus on each individual’s strengths. The TIP system operates through the following seven guidelines that provide a framework for the program and a community system that supports that framework:

Engaging young people through relationship development, person-centered planning, and a focus on their futures;

Providing tailored supports that are accessible, coordinated, and developmentally appropriate;

Ensuring a safety net of support by involving a young person’s parents, family members, and other informal and formal key players;

Focusing on acknowledging and developing personal choice and social responsibility with young people;

Enhancing a person’s competencies;

Maintaining an outcome focus; and,

Involving young people, parents, and other community partners in the TIP system at the practice, program, and community levels.

Assertive Community Treatment (ACT)

This community-based, multi-disciplinary approach was developed in the 1980s to provide treatment, rehabilitation, and support services to persons with severe and persistent mental illness. Using the ACT approach, cases are managed by a multi-disciplinary team, providing services directly to an individual that are tailored to meet his or her specific needs. A team may include members from the field of psychiatry, nursing, psychology, social work, substance abuse, vocational rehabilitation, and community-based organizations. Team members collaborate to deliver integrated services to individuals in their “natural living” settings instead of hospitals and clinics.

Systems of Care (SOC)

The SOC approach is characterized by multi-agency sharing of resources and responsibilities and by the full participation of professionals, families, and youth as active partners in planning, funding, implementing, and evaluating services and system outcomes. The SOC approach facilitates cross-agency coordination of services, regardless of where or how children and families enter the system. Families and youth work in partnership with public and private organizations to design mental health services and supports that are effective, that build on the strengths of individuals, and that address each person’s cultural and linguistic needs. SOC is characterized by multi-agency sharing of resources and responsibilities and by the full participation of professionals, families, and youth as active partners in planning, funding, implementing, and evaluating services.

Among the services critical to preparing transition-age youth for successful adulthood is competitive employment. According to the President’s New Freedom Commission on Mental Health, 90 percent of adults with serious mental illness are unemployed, the highest unemployment rate of any group of people with disabilities. This statistic underlines the importance of starting early to prepare young people with mental health needs for success in the workplace. Fortunately, the National Longitudinal Transition Study II, indicates that, within a one-year period, youth with mental health needs were employed at a slightly higher rate than youth in the general population.

The most effective way for youth to learn work skills is in competitive employment and other work-based learning experiences. An effective transition system will ensure the involvement of employers at all appropriate levels, including advisory boards, cooperative arrangements with transition programs, job-shadowing, mentoring, and employing youth with mental health needs. The system will also need to provide assistance to employers on such issues as disclosure, accommodations, and job modifications.

GAO found three of the four states they visited used supported employment, an evidence-based practice promoted by Substance Abuse and Mental Health Services Administration (SAMHSA), to help young people with mental health needs find and maintain competitive employment in their community. Programs using a supported employment strategy typically utilize employment specialists who place individuals receiving mental health services in competitive jobs that fit the individual’s interests and abilities as soon as possible rather then waiting until the individual is deemed pre-certified for work. Once placed, employment specialists continue to offer support and assistance for as long as the individual requests it.

State officials indicate housing is the most challenging need facing youth and young adults with mental health needs. While SAMHSA recommends supported housing for individuals with mental health needs, which combines housing with other needed wraparound services, the four states visited by GAO report a lack of supportive housing or a lack of such housing targeted to young adults.

Collaborate and Coordinate Across State and Local Agencies

Collaborative, cross-agency cooperation (both statewide and in local communities) is key to ensuring youth with mental health needs have access to the range of services tailored to their needs without having to navigate multiple systems and programs. It also allows agencies to maximize available expertise and to leverage funding for youth service delivery. For example, Connecticut’s Department of Mental Health and Addiction Services has coordinated with the Department of Children and Families and several other state agencies to administrate the Young Adult Services program since 1998. Offered in 16 of the 21 local mental health authorities, the Young Adult Services program provides a combination of mental health treatment, supported employment, vocational or educational support, life skills training, and supportive housing with the goal of helping young people achieve increasing levels of independence and success in the community. The particular array and level of care varies somewhat by location and with respect to the young person’s needs.

According to the 2008 GAO report, some of the ways agencies in the four states they visited are collaborating and coordinating include:

Establishing a Formal Referral Process Across Agencies: Connecticut’s mental health agency and the state agency responsible for foster care, juvenile justice, and youth mental health services have established a cooperative agreement outlining criteria by which young people may be referred to the state mental health agency’s young adult program. The agreement also spells out the role of each agency in delivering and funding services to the client during the transition period.

Creating Statewide and Local Interagency Task Forces: At the state level,Mississippi’s mental health agency formed an interagency Transitional Services Task Force in 2003 that includes officials from the state departments of Rehabilitation Services and Human Services (foster care) as well as representatives of a nonprofit advocacy group for individuals with mental illness and their families. The Task Force is responsible for developing policies, identifying resources, and monitoring implementation of the state’s young adult program. Multidisciplinary Assessmentand Planning Teams were formed at the local level as a means for officials from various state agencies and advocates to review youth cases and coordinate the delivery of multiple services including mental health, education, vocational rehabilitation, health care, and juvenile justice services.

Integrating Eligibility Determination and Service Delivery: Maryland’s mental health and vocational rehabilitation agencies established a cooperative agreement in 2007 to integrate their eligibility determination and service delivery process. Individuals who are determined eligible by the mental health agency are automatically deemed eligible for supported employment services by the vocational rehabilitation agency.

As agencies embark on a cross-agency planning process, they may find it useful to start with a resource mapping process, a type of environmental scanning used to identify, record, and disseminate related resources and services that comprise the youth services delivery system. Detailing current capacities, needs, and expertise will help the agencies involved make strategic decisions about ways to broaden their collective capacity. The beginning point can be to identify providers of youth services and their funding resources. Resource mapping allows states and communities to identify service gaps and service overlaps. This information is essential for aligning assessment services and for strategic planning.

Interagency strategic planning processes will need to consider program evaluation and reporting requirements for outcome measures and continuous improvement data. The often elaborate reporting requirements of federally funded partners will need to be factored into data sharing and data management agreements. These agreements should also take into account confidentiality and privacy issues. Data privacy practices of health, education, and human services organizations determine a portion of what must be addressed in any collaborative initiative among agencies and institutions.

Broaden Eligibility Criteria for Mental Health Services

While young people in many states lose their eligibility for mental health treatment and other supports due to the different eligibility criteria used by the child and adult systems, one state has removed this barrier for young adults by broadening the eligibility criteria. Although comprehensive adult mental health services are typically only offered to individuals with certain diagnoses and functional limitations, Maryland state officials have extended the eligibility for mental health services to young adults who do not meet all eligibility criteria. Officials have chosen to expand eligibility for young adults in an effort to reduce their future dependency on the service systems by helping them become productive members of the community. Other states could prevent service interruptions and discontinuity during young people’s transition to adulthood by making similar adjustments to eligibility criteria for young adults.

Involve Youth and Families in Policy Development

Just as young people with mental health needs and their families should be engaged in making decisions and plans regarding their current and future needs and goals, so should they be involved in policy development related to the systems, programs, and services aimed to help them. No one knows better what youth and young adults are experiencing, what challenges they are facing, and how to meet their needs than young people themselves. In their visits to four states, GAO found one state had strong youth and family involvement in policy decisions. When the Massachusetts mental health agency established a statewide Youth Development Committee in 2002 to focus on youth with mental health needs, it invited young adults with mental health needs and parents to serve as representatives as well as child and adult mental health state agency officials, transition experts, and other professionals. The Committee has given young adults significant leadership roles by involving young adults as committee co-chairs and appointing one representative from all areas of the state. The local youth representatives report back to the Committee on the status of service delivery in their areas. Through monthly meetings, the Committee conducts strategic planning, monitors service implementation, and identifies staff training needs. The Massachusetts Youth Leadership Academy provides opportunities for youth with mental health needs to network with peers and share information on issues such as substance abuse prevention and health insurance.

Leverage Various Federal and State Funding Sources

Financing multidimensional services for youth with mental health needs requires leveraging multiple funding streams and resources. GAO found the states they visited use the following funding resources and strategies to varying degrees:

Medicaid: States used it to cover CMS approved mental health services

Medicaid’s Rehabilitation Services Option: States that include “rehabilitation services” for individuals who are eligible for Medicaid in their state plans can cover a portion of youth program operating costs through Medicaid dollars.

CMS grants: Mississippi used the Real Choices System Change grant to implement a “person-centered planning” strategy for its young adult program.

State funds: States used their own funds to cover services for non-Medicaid eligible youth and services not covered by Medicaid.

SSI: Maryland required young people served by the public mental health system to apply for SSI and other public benefits to receive income assistance for housing, insurance, and to pay for services.

States have the authority to implement policies that widen service providers’ access to funding sources for serving youth and young adults with mental health needs. In the 2007 case studies report, Woolsey & Katz-Leavey suggested states utilize the following mechanisms to support and improve funding:

Develop and enact state legislation targeting transition-age youth: Indiana, for example, codified the Assertive Community Treatment (ACT) model in state law to ensure certain standards for Medicaid reimbursement are met.

Apply for Medicaid Waivers: States may consider ways to use waivers for Home and Community-Based Services, Research and Demonstration Projects, and the Freedom of Choice to promote services for transition-age youth.

Amend State Medicaid Plans: States have flexibility to choose certain optional services, such as Rehabilitation Services, for adults and to expand eligibility groups for Medicaid coverage.

Apply for SAMHSA State Incentive Grants: In an effort to support systems transformation as recommended by the President’s New Freedom Commission on Mental Health, these grants focus on states’ infrastructure and service delivery improvement activities.

Build the Competencies of Career Educators and Workforce Professionals

Professionals who work in the workforce development field as well as secondary education institutions need additional training and guidance to effectively work with all youth and young adults, including those with mental health needs. Currently, many of the youth mental health professionals who are effectively finding and expanding outreach and engagement strategies for youth and young adults with mental health needs do not have expertise in work and career preparation specifically. Career educators and workforce development professionals have that expertise, but do not have the specific knowledge of engaging young people with mental health needs. This is a classic situation of disconnection and could be addressed through demonstration projects.

Additional pilot demonstrations and evaluations are needed to develop, test, and recognize promising practices that help youth and young adults with mental health needs of all severities successfully transition into work, industry relevant education, and fulfilling careers. Input for designing such pilots including requirements for multi-agency coordination and funding commitments can be gathered from successful programs already in operation in states and local communities nationwide. Demonstrations should encourage (1) innovative approaches to the major barriers of cross-system collaboration, including sharing information across agencies and organizations; (2) implementation strategies that clarify and incorporate the youth voice across the continuum of empowerment - youth driven, youth directed, and youth guided; (3) connections that support transitional housing; (4) relationships with schools that create opportunities for earlier intervention to prevent the downward spiral of too many youth; and 5) an emphasis on work readiness and employment.

Many resources are available to inform policy development and program design and implementation. In addition to the Guideposts for Success for Youth with Mental Health Needs, NCWD/Youth in collaboration with ODEP developed the following guidance:

For more information on issues related to supporting youth and young adults with mental health needs, please contact the National Collaborative on Workforce and Disability for Youth at http://www.ncwd-youth.info.

U.S. Government Accountability Office, Report 08-678 (2008). Young Adults with Serious Mental Illness: Some States and Federal Agencies are Taking Steps to Address Their Transition Challenges. Washington, D.C.

The National Collaborative on Workforce and Disability for Youth (NCWD/Youth) is composed of partners with expertise in disability, education, employment, and workforce development issues. NCWD/Youth is housed at the Institute for Educational Leadership in Washington, DC. The Collaborative is charged with assisting state and local workforce development systems to integrate youth with disabilities into their service strategies. This Policy Brief was written by Mindy Larson.

To obtain this publication in an alternate format please contact the Collaborative at 877-871-0744 toll free or email contact@ncwd-youth.info. This Information Brief is part of a series of publications and newsletters prepared by the NCWD/Youth. All publications will be posted on the NCWD/Youth website at www.ncwd-youth.info. Please visit our site to sign up to be notified of future publications.

This document was developed by the National Collaborative on Workforce and Disability for Youth, funded by a grant/contract/cooperative agreement from the U.S. Department of Labor, Office of Disability Employment (Number #OD-16519-07-75-4-11). The opinions expressed herein do not necessarily reflect the position or policy of the U.S. Department of Labor. Nor does mention of trade names, commercial products, or organizations imply the endorsement by the U.S. Department of Labor. Individuals may produce any part of this document. Please credit the source and support of federal funds.